=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477833630
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACCIDENT & INJURY WELLNESS CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2011
-----------------------------------------------------
Last Update Date | 08/19/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1261 SOUTH PINE ISLAND ROAD
-----------------------------------------------------
City | PLANTATION
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-843-5962
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2612 NW 39TH ST
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-843-5962
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RICHARD JOEL ROSEN
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 561-843-5962
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 8447
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------